Estimated Prevalence of and Factors Associated With Clinically Significant Anxiety and Depression Among US Adults During the First Year of the COVID-19 Pandemic
Authors: Ronald C. Kessler, Christopher J. Ruhm, Victor Puac-Polanco, Irving H. Hwang, Sue Lee, Maria V. Petukhova, Nancy A. Sampson, Hannah N. Ziobrowski, Alan M. Zaslavsky, Jose R. Zubizarreta
Journal: JAMA Network Open (2022)

<h3>Importance</h3> Claims of dramatic increases in clinically significant anxiety and depression early in the COVID-19 pandemic came from online surveys with extremely low or unreported response rates. <h3>Objective</h3> To examine trend data in a calibrated screening for clinically significant anxiety and depression among adults in the only US government benchmark probability trend survey not disrupted by the COVID-19 pandemic. <h3>Design, Setting, and Participants</h3> This survey study used the US Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System (BRFSS), a monthly state-based trend survey conducted over the telephone. Participants were adult respondents in the 50 US states and District of Columbia who were surveyed March to December 2020 compared with the same months in 2017 to 2019. <h3>Exposures</h3> Monthly state COVID-19 death rates. <h3>Main Outcomes and Measures</h3> Estimated 30-day prevalence of clinically significant anxiety and depression based on responses to a single BRFSS item calibrated to a score of 6 or greater on the 4-item Patient Health Questionnaire (area under the receiver operating characteristic curve, 0.84). All percentages are weighted based on BRFSS calibration weights. <h3>Results</h3> Overall, there were 1 429 354 respondents, with 1 093 663 in 2017 to 2019 (600 416 [51.1%] women; 87 153 [11.8%] non-Hispanic Black; 826 334 [61.5%] non-Hispanic White; 411 254 [27.8%] with college education; and 543 619 [56.8] employed) and 335 691 in 2020 (182 351 [51.3%] women; 25 517 [11.7%] non-Hispanic Black; 250 333 [60.5%] non-Hispanic White; 130 642 [29.3%] with college education; and 168 921 [54.9%] employed). Median within-state response rates were 45.9% to 49.4% in 2017 to 2019 and 47.9% in 2020. Estimated 30-day prevalence of clinically significant anxiety and depression was 0.4 (95% CI, 0.0 to 0.7) percentage points higher in March to December 2020 (12.4%) than March to December 2017 to 2019 (12.1%). This estimated increase was limited, however, to students (2.4 [95% CI, 0.8 to 3.9] percentage points) and the employed (0.9 [95% CI, 0.5 to 1.4] percentage points). Estimated prevalence decreased among the short-term unemployed (−1.8 [95% CI, −3.1 to −0.5] percentage points) and those unable to work (−4.2 [95% CI, −5.3 to −3.2] percentage points), but did not change significantly among the long-term unemployed (−2.1 [95% CI, −4.5 to 0.5] percentage points), homemakers (0.8 [95% CI, −0.3 to 1.9] percentage points), or the retired (0.1 [95% CI, −0.6 to 0.8] percentage points). The increase in anxiety and depression prevalence among employed people was positively associated with the state-month COVID-19 death rate (1.8 [95% CI, 1.2 to 2.5] percentage points when high and 0.0 [95% CI, −0.7 to 0.6] percentage points when low) and was elevated among women compared with men (2.0 [95% CI, 1.4 to 2.5] percentage points vs 0.2 [95% CI, −0.1 to 0.6] percentage points), Non-Hispanic White individuals compared with Hispanic and non-Hispanic Black individuals (1.3 [95% CI, 0.6 to 1.9] percentage points vs 1.1 [95% CI, −0.2 to 2.5] percentage points and 0.7 [95% CI, −0.1 to 1.5] percentage points), and those with college educations compared with less than high school educations (2.5 [95% CI, 1.9 to 3.1] percentage points vs −0.6 [95% CI, −2.7 to 1.4] percentage points). <h3>Conclusions and Relevance</h3> In this survey study, clinically significant US adult anxiety and depression increased less during 2020 than suggested by online surveys. However, this modest aggregate increase could mask more substantial increases in key population segments (eg, first responders) and might have become larger in 2021 and 2022.